For this assessment, you will develop an 8-14 slide PowerPoint presentation with thorough speaker's notes designed for a hypothetical in-service session related to the safe medication administration improvement plan you developed in Assessment 2.
• List the purpose and goals of an in-service s...
1
4020 Assignment 3: Improvement Plan In-Service Presentation
Slide 1. Introduction
Thank you for attending this meeting. Today I would like us to talk about medication errors. I will discuss a case scenario that occurred a while back and the steps to take to avoid a future recurrence. Before I continue, I want you all to know that the administration appreciates your hard work in caring for our patients. The administration acknowledges that while no one intends to make an error, it is best that if each one of us took the responsibility to ensure that medication errors do not occur. Slide 2. Case Scenario
A 53-year-old male patient W.K was admitted to the ward following a new onset of the seizure. He had come to the healthcare facility because he worried over the meaning of the seizure. Although he had previously been on medication, he was started on Klonipin 1mg.
The new drug was not up from the pharmacy yet; nonetheless, the nurse stayed with the patient and educated him about the new medication he would start taking. A little while later, the nurse took a telephone order by the doctor for a different patient who had similar-
sounding names to the first patient W.K. The order placed for the second patient was Clonidine 0.1mg, and the medication was ordered by the nurse, who returned to the medication rooms to set up medications for yet another patient. Slide 3 2
When the nurse got to the medication room, another nurse looked through the medication trays and stated that she could not find her patient’s medication which the pharmacy had said was already dispensed. The first nurse realized her error when the second nurse said that the missing drug was Clonidine 0.1mg. At this point, the first nurse checked the medication label that she had on her hand and realized that the names on the label were not that of her patient but rather those of the second nurse’s patient. The birth date of the second patient was indicated on the label. The first patient’s doctor was informed of the medication error, and he ordered that the patient's vital signs be monitored for two hours and, consequently, for four hours but with two-hour intervals. Although the patient had a lowered blood pressure, she did not experience any adverse effects and recovered well. Slide 4. Safety Improvement Plan
What Went Wrong In this case scenario, the patients' names were similar to the medication names. However, the nurse failed to check the names in the wristband of the first patient as the policy
required. The nurse had spent some time with the patient and felt that she knew her well to bother checking the names on the wristband against that on the medication label. It was also indicated that other nurses did the same thing; they never followed the name and birth date policy in confirming a patient.
Also, the patient’s band information was illegible and made it hard to read. Although the two patients were in different rooms, the medication trays were placed on top of the other,
with nothing separating the two or warning of the similarity in names. Slide 5. What Should Have Been Done:
The staff must replace the patient’s label once it becomes illegible in the hospital's patient identification policy. Still, the nurse failed to do so in this case, which contributed to the medication error.
The benefits of buying summaries with Stuvia:
Guaranteed quality through customer reviews
Stuvia customers have reviewed more than 700,000 summaries. This how you know that you are buying the best documents.
Quick and easy check-out
You can quickly pay through credit card or Stuvia-credit for the summaries. There is no membership needed.
Focus on what matters
Your fellow students write the study notes themselves, which is why the documents are always reliable and up-to-date. This ensures you quickly get to the core!
Frequently asked questions
What do I get when I buy this document?
You get a PDF, available immediately after your purchase. The purchased document is accessible anytime, anywhere and indefinitely through your profile.
Satisfaction guarantee: how does it work?
Our satisfaction guarantee ensures that you always find a study document that suits you well. You fill out a form, and our customer service team takes care of the rest.
Who am I buying these notes from?
Stuvia is a marketplace, so you are not buying this document from us, but from seller samaritanwoman01. Stuvia facilitates payment to the seller.
Will I be stuck with a subscription?
No, you only buy these notes for $11.49. You're not tied to anything after your purchase.
